How Society, Science and Technology interact with each other

Menu

Tag Archives: Obamacare

I’m reading the book Messy The Power of Disorder to Transform our Lives right now. The author is a economist that looks at some pretty interesting topics, I enjoyed his book about failure and how failing typically leads to better results later in life for people that have tired a venture and failed, compared to those ventures that kind of limp along as zombies.

In this book, which to some extent is a natural extension of the failing book, Tim Harford discusses how a lack of a fully formed plan can actually result in significantly better results. However, this isn’t universal and cannot be applied in every circumstance. It’s important to note that, but he outlines some pretty clear ways that this approach works extremely successfully. Ultimately, I think he shows that strong planning that meshes with flexibility and allows for both improvisation and innovation works the best.

He describes Rommel’s campaign in Africa during WWII as one of the best examples of how this can be successful. Rommel, basically went from battle to battle continually pressing in using controlled chaos to dominate the British.

This is something called the OODA loop, Observe, Orient, Decide, Act – which is a rapid response approach to dealing with a chaotic situation. You have to observe to understand what’s happening, orient your plan to take advantage of the situation, decide your course of action, and then act on that. The faster and shorter you can make this loop the more you can keep your opponents on their heels.

Trump’s campaign, the book is rather new, is another case in point where continually pressing attacks and not looking back can be effective. He was very successful in attacking Rubio for his robotic responses, attacking Jeb Bush for just about anything while using these attacks as a way to keep himself front and center on the news. The media had no idea how to deal with him, because it requires a lot of people to produce content and planning from senior leadership to manage what should be included in a given segment.

The groups that were able to handle Trump the best were smaller organizations with more flexibility like The Intercept and contributing writers like the Young Turks, and Shaun King. These people were able to be much more nimble and respond because they either had editorial freedom, or could push out an article on a daily basis without much need of oversight.

These are the same people that draw the most criticism from the central planners, similar to Rommel, in the DNC and Establishment Democrats. DNC wants to manage the resistance and plan how they are to address the Trump issue complete. This is doomed for failure the same reason the Jeb failed. It’s too reactionary and cares too much about it’s own “Optics.”

To truly combat Trump, you must use similar tactics, continually pressing attacks. Continually keeping him on his heels, force him to jump from one thing to another, without really being able to focus on anything of actual import. The next step is to completely tie the republican establishment to Trump in every article and work to ensure that they are also back on their heels reacting to Trumps reaction.

These attacks must, of course, be factual and use a policy informed with stories of people to counteract Trump. The Repeal of Obamacare is the best place to use this tactic as there’s a lot of misinformation about it and there’s a lot success stories. However, playing the victim card won’t work here, because Trump loves victims and he thrives when people feel victimized.

So, I’m going to start blogging more about these sorts of topics and trying to use this approach to engage the other side to see what happens. Could be terrifying, but it’s something that must be done.

In my last Healthcare blog I argued that because of the structure of our payment system, the network effects of the providers, and reimbursement rules healthcare isn’t a free market. I believe that the exchanges in the Affordable Care Act aka Obamacare, actually offer a path forward that may take us closer to a freer market for healthcare than anything we currently have.

First I need to say that they are not an immediate silver bullet the exchanges only offer a way forward and do not guarantee any changes in the market. Furthermore, if the exchanges do provide the changes I’d like to see it will take time, several years in fact, for those changes to have a broader impact on the market.

What are the exchanges? They are essentially a market place where a customer can select a type of insurance with a specific network that meets their needs. How is this different than what we have had in the past? Well, typically health insurance has been only offered through your employer and you get what they offer. If you don’t have a full time job, you’re basically out of luck and paying a huge monthly premium. The exchanges level that playing field by increasing the pool of people that will be using those types of insurance and allowing across state competition for health insurance. For example, there’s only one Blue Cross Blue Shield provider across all the exchanges in the US. That’s a pretty big change.

Because there is competition based on meeting the needs of the customers there will be much faster feedback to the “plans” as they are called. If members don’t like a specific offering, they won’t make any money and the next year will be forced to make a different offering to attract more members. Furthermore, there will be switching across the plans as people realize they dislike certain features. I believe this will happen for several years until a “dominate” plan design emerges based on the success of those plans. Healthier members, low turn over, and acceptable level of revenues for the insurers. Expect these metrics to be similar to the mobile industry in the US (ARPU, Churn, etc..).

Because of the relatively fast feedback on the products in the market and the possibility to have at least three offerings on the exchange (Gold, silver, bronze), insurers can experiment with different types of plans and benefits. The most popular one at this point is something called Accountable Care Organization, which is somewhat similar to an HMO, but is supposed to be better (we’ll see). ACOs as they are called will have to keep track of the overall quality and re-admission rates with a goal of continually driving up quality of care and reduce re-admissions. Additionally, these are narrower networks of care than a traditional PPO that most people have become accustom to.

That’s fine, but that doesn’t really help with the fact that it’s a networked economy and that there’s still a huge imbalance of knowledge. Well, here’s where the insurers can changes things up. Instead of focusing on the narrow set of providers in their region, they can look to create a network based upon the specific of the member’s conditions and have those members go to the specialty providers that offer the best care for those conditions. Even if they are out of state or out of the country.

Granted this data is a bit out of date, however it’s likely to be accurate, according to the Innovator’s Prescription (pg 96) there are facilities that have become so specialized in certain conditions (hernia repair) that their cost to treat those conditions is $2,300 while a general hospital costs an average of $7,000 and has a much lower re-admission rate than the general hospital. With this in mind an insurer could use these specialty clinics and even fly their members to receive treatment and still save money.

This would dramatically change the shape of the network for the members of those insurers and improve overall care and results. It would also dramatically change the interaction with providers in the member’s region as well. Some hospitals are already feeling the pain in this such as Seattle’s Children’s Hospital (which is suing over being excluded).

I don’t think being exclusive it the right direction, I think creating a strong partnership with members through health coaching and care management can help drive better results and education between the provider, insurance company, and member.

This will require continual experimentation with the types of networks, the way the insurance companies interact with their members to take it from a confrontational interaction (from the member’s perspective), and how the providers plan to engage with insurers. There needs to be incentives to encourage providers to recommend non-traditional recommendations. Incentives to support healthy living for the members. Only experimentation in all of these areas can inform the insurers how to engage better to dramatically improve the health and reduce the cost of our nation.

The government shut down is bad mmmkay? This is one of the examples as to why I’m glad my wife didn’t end up with a job at either a government research lab, government agency, university or any other place that relies on public funds to keep it’s doors open. That’s a lot of places. Between the sequestration and this shutdown, the US has turned into a horrible place for the sciences. However, it’s alright for us to keep the NSA up and running, but not the people that watch the watchmen. Basically, our government has different priories than most Americans, which of course is no surprise – well at least different from myself. Losing funding for science is a huge blow, especially the fact that they couldn’t continue to speak or publish any papers. It’s disconcerting because our scientific research is what allows the US to stay ahead of the rest of the world in our economic output. The results of scientific funding from the ’60s essentially gave rise to everything we’re doing on the internet. The funding from ARPA that lead to ARPAnet and then the internet, inadvertently lead to the great work I mentioned in my review of Dealers of Lightning. Many of the members of the team at Xerox were funded by ARPA during their PhD’s, their research at various universities, and in some cases even startups. This one government expenditure had massive positive impact in the one area of our economy that’s going gang busters.

So what’s going on with this shutdown? As this article points out the House did pass a budget, which is where all budget must start, however, the Senate didn’t pass it and countered with their own budget, which happens fairly often. This leads to negotiation between the two chambers in Congress. The problem that we’re experiencing in this case is that the “don’t match” portion happens to be Obamacare. The House did not fund Obamacare at all, while the Senate naturally did (being held by the Democrats). This required that the House and Senate come together to reconcile their differences, which aren’t possible to reconcile with everyone. Which is the Speaker’s problem right now. Almost a week ago, there were rumored to be enough votes in the House to pass the Senate version of the budget – as Republicans were defecting to support the Democrats. The House refused to allow a vote to be called. Bills that don’t have a chance to pass get votes all the time (many people have pointed out Obamacare repeal is a key example of that). So, I think that the article I linked above is a bit disingenuous either intentionally or is just intellectually dishonest. The author clearly knows what people mean by saying “law of the land.” It means that as we have obligation within the law we need to pay them. The House, Senate, President, and Supreme Court weighed in and it’s a legal bill. The House is unable to repeal it through legislative methods so created a plan to shutdown the government to stop the bill from taking effect – to defund the bill and “repeal” it that way. That’s what they are doing and why.

The reasons for why the Republicans believe this would work is beautifully laid out in an argument using Game Theory on the Harvard Business Review: every other time brinkmanship was used, it worked. Go with the strategy until it doesn’t work any more. The White House figured this out too and now cannot allow it to continue. Otherwise, the above author would be correct, the best way to kill a bill you don’t like that passed through everything is to simply defund it later or shutdown the government until the other people meet your demands. Toss some spin on their to make it seem like the other side is unreasonable and boom, you’ve gotten your way again.

The problem with brinkmanship is that it’s a zero sum game and if the government defaults, it’s going to be terrible for everyone. The bulk of US voters blame the republicans, this could cause massive damage to even safe areas for the republicans. Are there better ways to deal with Obamacare? Yes, if it’s as awful as the Republicans think it is, use that to get everyone out of office that voted for it. Run on that plank and push it to the hilt. If it kills jobs, causes people to go bankrupt use all that to get the Democrats out of office. Then once a majority is secured repeal the law. That’s how government should work. Sure you can work to undermine the law while you’re at it, but if you want to get rid of it, do it with votes so it’s clear the people have spoken. This shut down is bad for everyone. Let’s end it, figure out how to address long term debt, improve the job market, pay for more science, and address the structural problems we have as a nation. If Obamacare is a bad thing, we’ll figure it out really quick and then deal with that fall out. We need leaders now, not children.